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r �SAPPLICATION FOR WELLIPUMP PERMIT m JOAOUIN COUNTY PUB1IC HEALTH SERVICES i ENVIRONMENTAL HEALTH DIVISION P.4, BOX 388,304 EAST WEBER AVENUE,STOCKTON, CA VM1-88 (209) 408.3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FR014 DATE ISSUED (Complete In Triplkalel j APPLICATION 19 HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION 18 MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE.CHAPTER 9-1116.3 AND THE STAN ARDS OF BAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESS/OR APN# tn�'^�LIk�G Oa c1re I✓�r4( PARCE�SIZ�APNe /�. f sj— OWNER'S NAME ADDRESS WONEP S. S �� PHONE 23 IF CONTRACTOR �- ADDRESS C1�6� QO PHONE - i OUR CONTRACTOR .S Z- I ADDRESSRZ_, ! ')2 a&r+" LI 9 PHONE - Z7.� { # TYPE OF WELLJPUMP. ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL s ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL! ,1 ❑New 13 Repelr H.P. DEPTH PRIMP SET FT. FIRST WATER LEVEL t7 {TYPE OF PUMP) ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL! ❑ SOIL BOMHO 1 A ESTRVCTION: �� •f�GC/� �� fiG - S ✓' -� LJ'T INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO D ❑ DOMESTIC/PRIVATE ❑ORAVEL PACKIBIZE TYPE OF CASINGISTEELIPVC CIA.OF WELL CASING D ❑ PUBLICIMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION p ❑ IRRGATIONIAG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME d E ❑ MONITORING GROUT SEAL PUMPED: ❑Vee ❑No CONCRETE PEDESTAL BY DRILLER:❑Yoo ❑Na S APPROX,DEPTH LOCKING CHESTER BOX/STOVE PIPE S ` PROPOSED CONSTRUCT'IONMRELUNG METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER 1 HEREBY CERTIFY THAT I RIAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL,BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF THE SAN JOAQUIN COUNTY, HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,1814ALL NOT EMPLOY PERSONS SUBJECT TO WORKMANr6 COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR BUB-CONTRACTING SIGNATURE CERFIFTES THE FOLLOWING: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICH THIS PERMIT IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMMSATTON LAWS OF CALIFORNI=11, "TT MUST CALL 24[OURS IN ADVANCE FOR ALL NEGUIRED INSPECTIONS AT 120014SS$42i, COMPLETE DRAWING AT LOWER AREA PROVIDED. signed Xl/L-, � ,�,.._, Title [ Q( .�, - Dote s J PLOT POLAR Rhew.to Salve)Boole to 1. NAMES OF STREETS OR ROADS NEAREST TO OR ROUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED �F 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION, EXPANSION OF SEWAGE DISPOSAL SYSTEMS. I d. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS Or ONE HUNDRED FIFTY FT, STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY, 7- .. .-... ....E :., .. ... :... �-- ......�•• _�= —�: ."ase err i . DEPARTMENT USE ONLY Cj ApplleeHen Aaeeplerl Hy Dole / � q Growl Inopeetion Sy Dote Pump Inopeetlen By Dole D"I'mHan Inepeallon BY Dole ~14 ACCOUNTING ONLY: AID# FAC/ PE CODES FEE INFO AMOUNT REMITTED CHE CASH RECEIVED BY DA E PERMITISERVICE REQUEST NUMBER INVOICE ,t�Z, �� L Q S olS7oaa Pub.Health Serv.-Enviro.173(3196)